Main indications for alar rim grafts.
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-signs-new-contract-with-cepiec-china-for-distribution-of-open-access-books-20210319",title:"IntechOpen Signs New Contract with CEPIEC, China for Distribution of Open Access Books"},{slug:"150-million-downloads-and-counting-20210316",title:"150 Million Downloads and Counting"},{slug:"intechopen-secures-indefinite-content-preservation-with-clockss-20210309",title:"IntechOpen Secures Indefinite Content Preservation with CLOCKSS"},{slug:"intechopen-expands-to-all-global-amazon-channels-with-full-catalog-of-books-20210308",title:"IntechOpen Expands to All Global Amazon Channels with Full Catalog of Books"},{slug:"stanford-university-identifies-top-2-scientists-over-1-000-are-intechopen-authors-and-editors-20210122",title:"Stanford University Identifies Top 2% Scientists, Over 1,000 are IntechOpen Authors and Editors"},{slug:"intechopen-authors-included-in-the-highly-cited-researchers-list-for-2020-20210121",title:"IntechOpen Authors Included in the Highly Cited Researchers List for 2020"},{slug:"intechopen-maintains-position-as-the-world-s-largest-oa-book-publisher-20201218",title:"IntechOpen Maintains Position as the World’s Largest OA Book Publisher"},{slug:"all-intechopen-books-available-on-perlego-20201215",title:"All IntechOpen Books Available on Perlego"}]},book:{item:{type:"book",id:"112",leadTitle:null,fullTitle:"Effective Video Coding for Multimedia Applications",title:"Effective Video Coding for Multimedia Applications",subtitle:null,reviewType:"peer-reviewed",abstract:"Information has become one of the most valuable assets in the modern era. Within the last 5-10 years, the demand for multimedia applications has increased enormously. Like many other recent developments, the materialization of image and video encoding is due to the contribution from major areas like good network access, good amount of fast processors e.t.c. Many standardization procedures were carrried out for the development of image and video coding. The advancement of computer storage technology continues at a rapid pace as a means of reducing storage requirements of an image and video as most situation warrants. Thus, the science of digital video compression/coding has emerged. This storage capacity seems to be more impressive when it is realized that the intent is to deliver very high quality video to the end user with as few visible artifacts as possible. Current methods of video compression such as Moving Pictures Experts Group (MPEG) standard provide good performance in terms of retaining video quality while reducing the storage requirements. Many books are available for video coding fundamentals.This book is the research outcome of various Researchers and Professors who have contributed a might in this field. This book suits researchers doing their research in the area of video coding.The understanding of fundamentals of video coding is essential for the reader before reading this book. The book revolves around three different challenges namely (i) Coding strategies (coding efficiency and computational complexity), (ii) Video compression and (iii) Error resilience. 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He is a reviewer of 16 international journals namely IEEE Transactions on Systems, Man, and Cybernetics: Systems by IEEE, International Arab Journal of Information Technology coming from Zarqa University, International Journal of Computer and Electrical Engineering published by International Association of Computer Science and Information Technology Press (IACSIT),International Journal of Computer Theory and Engineering published by International Association of Computer Science and Information Technology Press (IACSIT), Journal of Electrical and Electronics Engineering Research, Iranian Journal of Electrical and Computer Engineering, Journal of Optical Engineering, Journal of Electronic Imaging, Imaging Science Journal, International Journal of Computational Science and Engineering (IJCSE), International journal of Image mining(IJIM), Int. 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He received his Ph.D. degree from Integral University on his work titled ‘Development and evaluation of silymarin nanoformulation for hepatic carcinoma’. Currently, he’s working as an Assistant Professor of Pharmaceutics in the Faculty of Pharmacy, Integral University. He has been teaching Pharm.D, B.Pharm, and M.Pharm students and conducting research in the novel drug delivery domain. From 2013 to 2014 he worked on a research project funded by SERB-DST, Government of India. He has a rich publication record with more than 24 original articles published in reputed journals, 2 edited books with IntechOpen, 4 book chapters, and a number of scientific articles published in ‘Ingredients South Asia Magazine’ and ‘QualPharma Magazine’. He is a member of the American Association for Cancer Research, International Association for the Study of Lung Cancer, and the British Society for Nanomedicine. 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He acted as Head of Department from 2014 till 2016. He also has experience of teaching abroad and has served as a Professor at Buraydah College of Dentistry and Pharmacy, KSA. Dr. Akhtar has more than 40 publications in reputed journals and is also editorial member of many esteemed journals. He has supervised a dozen of PhD and M.Pharm students in research projects. 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In spite of deep inspiration, nasal tip maintains its general shape through different mechanisms. Major mechanisms include
A representation of the main cartilages from a basal perspective: 1.
Normal alar contour is defined by well-defined alar margins and extension from the tip lobe to the alar lobe. The inferior lateral cartilages act as a dynamic spring that can resist small traumatisms, providing some elasticity to the nasal tip to prevent a collapse of the nasal
Positioning of the alar cartilages is a fundamental element when planning a rhinoplasty. An overenthusiastic resection may cause their weakness and inability to perform their sustaining role.
\nAn inadequate positioning of the alar cartilages entails an instable Anderson tripod with alar pinching. This may be a consequence of the resection of ligaments and the septal angle in order to achieve a reduction in nasal tip projection in open rhinoplasty procedures.
\nLess frequently, inborn asymmetries of the alar cartilages produce unbalance and rotation of the nasal tip. Moreover, some patients may suffer from a cephalad rotation of the alar cartilages; they may orientate their main axis toward the inner cantus without giving adequate support to the external valve.
\nAlar and perialar rim grafts are rods or little splints made of cartilage. They are placed under the caudal margin of alar cartilages. They may be applied for primary and secondary rhinoplasty. Alar rim grafts were heralded as early as the 1950s by Fomon [1, 2] and Denecke [3] for the correction of alar base in cleft lip nose. Composite paranasal grafts on the nasal mucosa (instead of
With greater emphasis focused on correcting the collapse of the internal valve, this approach by alar rim grafts was a sleeper. It was not until recent times when some surgeons [8, 9, 10] pointed to its potential role in aesthetic cases and added some technical refinements (Figure 2).
\nTesting of the general elasticity and passive collapse of the nasal tip and
Alar rim grafts may be used for treatment and prevention of disorders of the nasal tip outline. They have been advised for the treatment of alar deformities. These deformities may stem not only from malposition or congenital hypoplasia of inferior lateral cartilages but also from a loss of continuity or a weakening of
Congenital asymmetry | \n
Dynamic alar collapse | \n
Alar flare (without functional impairment) | \n
Primary retraction or notching | \n
Secondary (surgical or traumatic) retraction as in pinched tip | \n
Malposition of the lateral cartilages (upwards/downwards, bulbous tip, square tip) | \n
Congenital microrrhinia (all nasal dimensions affected as seen in foetal alcoholic syndrome) | \n
Main indications for alar rim grafts.
The position and dimension of the nasal
alar retraction—an elevation of the inferior concavity of the arch;
hanging alar rim;
retracted columella; and
hanging columella—the inner mucosal lining of the medial aspect of each narine is conspicuous.
(A) Anatomical variations and primary alterations of alar contour include (from left to right) pinched lobes, undulating alar cartilages, visible margins, bulbous tip and parallel orientation of both alar cartilages. (B) Some features that may involve alar rim grafts as a treatment include (from left to right) lack of sustentation of alar rim, high positioned soft triangle, bulbous tip and square tip.
Functional primary disturbances may be the main motivation for a rhinoplasty (though they are also seen as an undesired side effect of a previous operation). These disturbances may cause difficulties in breathing, altered olfactory function, bleeding and frequent infection. Pre-operative rhinoscopy in order to exclude upper functional conditions (septal deviation, hypertrophic cornets, collapse of the upper internal valve and polyps) must be always carried out. A hanging tip is assessed by pinching the skin of the nasal dorsum. The collapse of the upper internal valve is sometimes evident after mild finger traction on the maxillary ascending apophysis. A cotton tip moisturised in adrenaline produces vasoconstriction and reduction in the size of hypertrophied cornets. A collapse of the lower valve may be corrected by gently opening the tweezers inside the air passage.
\nInspection of the nasal external valve constitutes an unavoidable step toward the end of any rhinoplasty procedure. Whenever we have performed a reduction of the projection of the nasal tip, we shall get an alar excess. Scar lines or excessive resection may entail a narrowing of the air passage. We use these grafts for open and closed rhinoplasties. The graft consists of a rod of septal or auricular cartilage (Figure 4A
(A) A sketch of the positioned alar rim graft in a frontal view. (B) The positioned alar rim graft in a lateral view.
Intraoperatory appreciation of the required length of grafts.
Incision, blunt dissection and insertion of an alar rim graft.
When performing an open rhinoplasty, we use the same pre-rimal incision. Thus, we can check the symmetry of graft positioning. When performing a closed rhinoplasty, we place the grafts through a marginal incision (1 mm from the alar rim) and we extend the pocket frontwards to the soft triangle and backwards to the caudal end of the ala. We first lay the graft inside the posterior pocket and by careful sliding, we position its crushed edge inside the anterior pocket.
\nAn alternative method involves conchal cartilage extension grafts fixed to the caudal margins of the lateral crura as described by Jang et al. [20]. This hybrid method focuses on correcting anterior contraction of the alar rim as seen in East Asian patients with nostril exposure. Alar vestibular skin is dissected at the end of an open approach for augmentation rhinoplasty. Conchal cartilage grafts are fashioned in a semilunar shape (13 mm × 6 mm) and sutured to the caudal margins of each
Articulated alar rim grafts [21, 22] stand as an interesting concept. In this widespread variation, the anterior margin of each alar rim graft is sutured to the tip complex instead of just being freely sited in a pocket. Emphasis is mainly made to stabilise the nasal tip.
\nA peculiar variation [23] elevates a 2–3 mm flap from the caudal portion of the
Selected cases of external nasal valve collapse as an isolated condition have been treated by a microinvasive technique that creates the pocket from the cutaneous, facial aspect of the posterior margin of the ala [24].
\nNeedless to say, versatile surgeons should bear in mind alternative donor sites as part of their armamentarium [25]. A posterior incision is the less conspicuous choice when taking conchal grafts Adequate semicompressive dressings and anaesthetic infiltration of the margins of the skin (for instance with bupivacaine or ropivacaine) would minimise haematoma and post-operative pain in this donor area.
\nAs with any surgical procedures, patients should be informed about potential problems as transient inflammation, haemorrhage, haematoma, seroma, adherences, conspicuous scarring, keloids and pigmentation alterations. The same goes for undesirable infectious conditions as chondritis, osteitis, myositis and abscess. More specific conditions are paraesthesia, loss of temperature sensation and partial resorption of the cartilaginous graft. Jarring right-left asymmetry of the grafts may entail pyramid deviation.
\nLocal necrosis and extrusion of the graft are very rarely seen. They may be the result of local traumatism or inadequate dressing as well as previous ischaemic features as seen in chain smoking (Figures 7, 8, 9, 10).
\n(A) Broad, bilobed nasal tip in a 27-year-old female patient. Slight deviation of dorsum and retracted columella. (B) Surgical planning for the patient in
(A) A 32-year-old female patient suffering for traumatic deviation. Hanging tip, acute nasolabial angle, broad tip and unbalance between lobe and
(A) A 35-year-old male patient with supratip deformation after secondary rhinoplasty. He showed a thick skin, a saddle (broad and flat) dorsum as well as an asymmetric, pinched tip, other features include an osseous dehiscence on the left side and malpositioned, undulating
(A) Secondary rhinoplasty in a 29-year-old female patient that showed deviation, irregularities of her dorsum, upper valve collapse, pinched tip, light alar retraction, hanging columella and maxillary hypotrophy. (B) Surgical planning for the patient in
These grafts are useful to prevent an alar retraction and post-operative shifts on those patients that show primary alterations of alar outline. They provide support and steadiness for the alar rim by creating a structure that counteracts the forces of scar contraction [26, 27, 28, 29]. Whenever we use them we shall prevent descent (or rotation) of caudal margin of alar cartilages and a trilobulate, pinched nose. At the same time, we enhance a correct functioning of the external valve and prevent its collapse.
\nThese grafts are also very useful for the treatment of pinched, nasal tips with a very long
In spite of deep inspiration, nasal tip maintains its general shape through different mechanisms. Major mechanisms include
A representation of the main cartilages from a basal perspective: 1.
Normal alar contour is defined by well-defined alar margins and extension from the tip lobe to the alar lobe. The inferior lateral cartilages act as a dynamic spring that can resist small traumatisms, providing some elasticity to the nasal tip to prevent a collapse of the nasal
Positioning of the alar cartilages is a fundamental element when planning a rhinoplasty. An overenthusiastic resection may cause their weakness and inability to perform their sustaining role.
\nAn inadequate positioning of the alar cartilages entails an instable Anderson tripod with alar pinching. This may be a consequence of the resection of ligaments and the septal angle in order to achieve a reduction in nasal tip projection in open rhinoplasty procedures.
\nLess frequently, inborn asymmetries of the alar cartilages produce unbalance and rotation of the nasal tip. Moreover, some patients may suffer from a cephalad rotation of the alar cartilages; they may orientate their main axis toward the inner cantus without giving adequate support to the external valve.
\nAlar and perialar rim grafts are rods or little splints made of cartilage. They are placed under the caudal margin of alar cartilages. They may be applied for primary and secondary rhinoplasty. Alar rim grafts were heralded as early as the 1950s by Fomon [1, 2] and Denecke [3] for the correction of alar base in cleft lip nose. Composite paranasal grafts on the nasal mucosa (instead of
With greater emphasis focused on correcting the collapse of the internal valve, this approach by alar rim grafts was a sleeper. It was not until recent times when some surgeons [8, 9, 10] pointed to its potential role in aesthetic cases and added some technical refinements (Figure 2).
\nTesting of the general elasticity and passive collapse of the nasal tip and
Alar rim grafts may be used for treatment and prevention of disorders of the nasal tip outline. They have been advised for the treatment of alar deformities. These deformities may stem not only from malposition or congenital hypoplasia of inferior lateral cartilages but also from a loss of continuity or a weakening of
Congenital asymmetry | \n
Dynamic alar collapse | \n
Alar flare (without functional impairment) | \n
Primary retraction or notching | \n
Secondary (surgical or traumatic) retraction as in pinched tip | \n
Malposition of the lateral cartilages (upwards/downwards, bulbous tip, square tip) | \n
Congenital microrrhinia (all nasal dimensions affected as seen in foetal alcoholic syndrome) | \n
Main indications for alar rim grafts.
The position and dimension of the nasal
alar retraction—an elevation of the inferior concavity of the arch;
hanging alar rim;
retracted columella; and
hanging columella—the inner mucosal lining of the medial aspect of each narine is conspicuous.
(A) Anatomical variations and primary alterations of alar contour include (from left to right) pinched lobes, undulating alar cartilages, visible margins, bulbous tip and parallel orientation of both alar cartilages. (B) Some features that may involve alar rim grafts as a treatment include (from left to right) lack of sustentation of alar rim, high positioned soft triangle, bulbous tip and square tip.
Functional primary disturbances may be the main motivation for a rhinoplasty (though they are also seen as an undesired side effect of a previous operation). These disturbances may cause difficulties in breathing, altered olfactory function, bleeding and frequent infection. Pre-operative rhinoscopy in order to exclude upper functional conditions (septal deviation, hypertrophic cornets, collapse of the upper internal valve and polyps) must be always carried out. A hanging tip is assessed by pinching the skin of the nasal dorsum. The collapse of the upper internal valve is sometimes evident after mild finger traction on the maxillary ascending apophysis. A cotton tip moisturised in adrenaline produces vasoconstriction and reduction in the size of hypertrophied cornets. A collapse of the lower valve may be corrected by gently opening the tweezers inside the air passage.
\nInspection of the nasal external valve constitutes an unavoidable step toward the end of any rhinoplasty procedure. Whenever we have performed a reduction of the projection of the nasal tip, we shall get an alar excess. Scar lines or excessive resection may entail a narrowing of the air passage. We use these grafts for open and closed rhinoplasties. The graft consists of a rod of septal or auricular cartilage (Figure 4A
(A) A sketch of the positioned alar rim graft in a frontal view. (B) The positioned alar rim graft in a lateral view.
Intraoperatory appreciation of the required length of grafts.
Incision, blunt dissection and insertion of an alar rim graft.
When performing an open rhinoplasty, we use the same pre-rimal incision. Thus, we can check the symmetry of graft positioning. When performing a closed rhinoplasty, we place the grafts through a marginal incision (1 mm from the alar rim) and we extend the pocket frontwards to the soft triangle and backwards to the caudal end of the ala. We first lay the graft inside the posterior pocket and by careful sliding, we position its crushed edge inside the anterior pocket.
\nAn alternative method involves conchal cartilage extension grafts fixed to the caudal margins of the lateral crura as described by Jang et al. [20]. This hybrid method focuses on correcting anterior contraction of the alar rim as seen in East Asian patients with nostril exposure. Alar vestibular skin is dissected at the end of an open approach for augmentation rhinoplasty. Conchal cartilage grafts are fashioned in a semilunar shape (13 mm × 6 mm) and sutured to the caudal margins of each
Articulated alar rim grafts [21, 22] stand as an interesting concept. In this widespread variation, the anterior margin of each alar rim graft is sutured to the tip complex instead of just being freely sited in a pocket. Emphasis is mainly made to stabilise the nasal tip.
\nA peculiar variation [23] elevates a 2–3 mm flap from the caudal portion of the
Selected cases of external nasal valve collapse as an isolated condition have been treated by a microinvasive technique that creates the pocket from the cutaneous, facial aspect of the posterior margin of the ala [24].
\nNeedless to say, versatile surgeons should bear in mind alternative donor sites as part of their armamentarium [25]. A posterior incision is the less conspicuous choice when taking conchal grafts Adequate semicompressive dressings and anaesthetic infiltration of the margins of the skin (for instance with bupivacaine or ropivacaine) would minimise haematoma and post-operative pain in this donor area.
\nAs with any surgical procedures, patients should be informed about potential problems as transient inflammation, haemorrhage, haematoma, seroma, adherences, conspicuous scarring, keloids and pigmentation alterations. The same goes for undesirable infectious conditions as chondritis, osteitis, myositis and abscess. More specific conditions are paraesthesia, loss of temperature sensation and partial resorption of the cartilaginous graft. Jarring right-left asymmetry of the grafts may entail pyramid deviation.
\nLocal necrosis and extrusion of the graft are very rarely seen. They may be the result of local traumatism or inadequate dressing as well as previous ischaemic features as seen in chain smoking (Figures 7, 8, 9, 10).
\n(A) Broad, bilobed nasal tip in a 27-year-old female patient. Slight deviation of dorsum and retracted columella. (B) Surgical planning for the patient in
(A) A 32-year-old female patient suffering for traumatic deviation. Hanging tip, acute nasolabial angle, broad tip and unbalance between lobe and
(A) A 35-year-old male patient with supratip deformation after secondary rhinoplasty. He showed a thick skin, a saddle (broad and flat) dorsum as well as an asymmetric, pinched tip, other features include an osseous dehiscence on the left side and malpositioned, undulating
(A) Secondary rhinoplasty in a 29-year-old female patient that showed deviation, irregularities of her dorsum, upper valve collapse, pinched tip, light alar retraction, hanging columella and maxillary hypotrophy. (B) Surgical planning for the patient in
These grafts are useful to prevent an alar retraction and post-operative shifts on those patients that show primary alterations of alar outline. They provide support and steadiness for the alar rim by creating a structure that counteracts the forces of scar contraction [26, 27, 28, 29]. Whenever we use them we shall prevent descent (or rotation) of caudal margin of alar cartilages and a trilobulate, pinched nose. At the same time, we enhance a correct functioning of the external valve and prevent its collapse.
\nThese grafts are also very useful for the treatment of pinched, nasal tips with a very long
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